WRITTEN EXAMINATION

PRE-INVESTIGATIVE QUESTIONNAIRE

IT IS MANDATORY THAT ALL INFORMATION REQUESTED BE SUPPLIED. EACH

QUESTION MUST BE ANSWERED; LEAVE NO BLANKS. IF A QUESTION DOES NOT

APPLY, ENTER “DNA” IN THE SPACE PROVIDED. PLEASE PRINT, LEAVE NO BLANKS.

________________________________________________________________________ LAST NAME FIRST NAME MI

______________ _________________________ _________________________________

STATE DRIVER’S LICENSE # DATE OF BIRTH

SOCIAL SECURITY NUMBER : _________________________

TELEPHONE NUMBER : _________________________

_________________________________ _________________________________

RESIDENCE ALTERNATE

_________________________________ _________________________________

INTERVIEWER DATE

ADMONISHMENT

The Pre-Investigative questionnaire you are about to fill out is a

very important document to you. It becomes a permanent part of

your file and will be reviewed several times before you are accepted

for hire. It has the potential for disqualifying you.

You will find questions pertaining to the use of narcotics, your

driving record, thefts, etc. Not all admissions in these areas are

disqualifying. For example, some use of illegal narcotics of drugs is

not automatically disqualifying. It is evaluated on a case-by-case

basis. However, falsifying your answers or deliberately omitting

information will be cause for disqualification.

As of January 1, 1990, all applicants are polygraphed prior to being

accepted for hire. Therefore, it is in your best interest to be

thorough and completely honest in your answers. Integrity weighs

heavily in the evaluation of any applicant being considered for hire.

Do you understand this admonishment? Yes _____ No _____

Do you have any questions about this admonishment? Yes _____ No _____

x _________________________________ Print Name

_________________________________

Social Security No.

_________________________________

Signature

_________________________________

Date

APPLICATION AND HISTORY RECORD

Please Print in Ink

PERSONAL INFORMATION :

DATE OF APPLICATION

POSITION APPLIED FOR LEGAL LAST NAME FIRST MI

SEX

AGE HEIGHT WEIGHT HAIR EYES SOCIAL SECURITY NUMBER

RESIDENCE ADDRESS (NO., CITY, STATE, ZIP)

LIVING WITH (PARENTS, FRIEND, ALONE,

OR RELATIVE)

MILITARY INFORMATION :

WHILE IN THE SERVICE, WERE YOU EVER THE SUBJECT OF ANY DISCIPLINARY ACTION SUCH AS: CAPTAIN’S MAST,

COURT MARTIAL, OFFICE HOURS, COMPANY PUNISHMENT, OR

ARTICLE 15? YES ( ) NO ( )

IF “YES”, EXPLAIN :

IF YOU RECEIVED OTHER THAN AN HONORABLE DISCHARGE, EXPLAIN :

EDUCATION INFORMATION :

LIST HIGH SCHOOL GRADUATED FROM OR LAST HIGH SCHOOL ATTENDED.

NAME OF SCHOOL CITY AND STATE

ATTENDANCE DATES

GRAD?

CALIFORNIA PROFICIENCY TEST

FROM TO YES WHEN TAKEN

FINANCIAL INFORMATION :

HAVE YOU OR YOUR SPOUSE :

YES NO ANY IMMEDIATE CIVIL ACTION PENDING AGAINST YOU?

YES NO EVER FILED BANKRUPTCY OR BEEN DECLARED BANKRUPT?

YES NO EVER BEEN DELINQUENT IN YOUR TAXES?

YES NO EVER HAD A BOND REFUSED?

IF THE ANSWERS TO ANY OF THE ABOVE QUESTIONS ARE “YES”, EXPLAIN IN DETAIL BELOW:

ARREST INFORMATION :

EITHER AS AN ADULT OR JUVENILE, HAVE YOU EVER BEEN DETAINED FOR INVESTIGATION, NAMED AS A SUSPECT

IN A POLICE REPORT, HELD ON SUSPICION, QUESTIONED, FINGERPRINTED, OR ARRESTED BY ANY LAW

ENFORCEMENT AGENCY OR MILITARY AUTHORITY? YES ( ) NO ( )

DATE CHARGE ARRESTING OR DETAINING AGENCY PENALTY

TRAFFIC INFORMATION :

HAS YOUR DRIVER’S LICENSE EVER BEEN SUSPENDED, REVOKED, OR PLACED ON PROBATION? YES ( ) NO ( )

IF “YES”, EXPLAIN:

LIST EVERY CITATION RECEIVED FOR A MOVING OR EQUIPMENT VIOLATION IN THE PAST THREE YEARS.

DATE CHARGE ARRESTING OR DETAINING AGENCY PENALTY

HAVE YOU EVER BEEN INVOLVED IN A TRAFFIC ACCIDENT? YES ( ) NO ( )

IF “YES”, DESCRIBE EACH ACCIDENT IN A BRIEF NARRATIVE BELOW.

INCLUDE DATES, LOCATIONS, POLICE AGENCY INVOLVED, AND WHETHER OR NOT YOU RECEIVED A CITATION.

PRE-INVESTIGATIVE QUESTIONNAIRE

Read and answer the following questions carefully and honestly. Answers are

subject to verification by a polygraph examination.

A “yes” answer is not in and of itself grounds for disqualification whereas an

untruthful response will be.

CRIMINAL AND ARREST INFORMATION 1. Have you ever committed any of the following acts?

a. Arson (intentionally starting a fire) Yes _____ No _____

b. Burglary (entry of a building or vehicle to commit a theft or other crime) Yes _____ No _____

c. Robbery (theft from another person using weapon or force) Yes _____ No _____

d. Homicide Yes _____ No _____

e. Theft Yes _____ No _____

f. Forgery Yes _____ No _____

g. Kidnaping Yes _____ No _____

h. Extortion (blackmail) Yes _____ No _____

i. Embezzlement (theft of money or other valuables entrusted to you) Yes _____ No _____

j. Rape (sexual intercourse by force) Yes _____ No _____

k. Any other forcible sex act (oral copulation, sodomy, etc.) Yes _____ No _____

l. Assaulted or hit another person Yes _____ No _____

m. Hit your spouse, girlfriend, boyfriend, etc. Yes _____ No _____

n. Witnessed or been the victim of domestic violence Yes _____ No _____

o. Been involved in a fight, whether you started it or not Yes _____ No _____

If you answered “yes,” check the appropriate box:

□ 1-5 fights □ 6-10 fights □ 11-15 fights □ More than 15 fights

If “yes” to any of the above, please indicate the question and explain:

2. Have you ever been accused of stealing from an employer? Yes _____ No ____

Explain:

3. Have you ever illegally used or experimented with any of the following substances,

drugs, or narcotics? (Used any of the following list of narcotics not prescribed

by doctor by the means of injection, tasting, inhaling, smoking, snorting, or hot-

boxing.)

DRUG

*Please indicate the month and year for first and last use of the drug.

YES NO

AMPHETAMINES: Amp, Black Bombers, Crank, Little Bomb, Speed, Nitro

Quartz, Johnny Go Fast, Uppers, Moni Bennie, Road Dope, Pink Hearts, UPS, Pep

Pills Copilots, Bumble-bees, Hearts, Footballs, Wake-Ups, Truck Drivers, Eye

Openers, Cross Tops, White Crosses, Crystals, Black Mollies, Peaches, Roses, Whites,

Bennies, Dexies.

First use ________ Last use ________ Total times used ________

AMYL NITRITE: Pearls, Ames, Amy, Poppers, Snappers.

First used ________ Last use ________ Total times used ________

BARBITURATES: Marshmellows, Reds Mickey, Ups and Downs, Downers, Barbs,

Nimbies, Nemmies, Yellows, Yellow Jackets, Blues, Blue Birds, Blue Devils, Red

Birds, Pinkies, Pink Ladies, Rainbows, Double Trouble, Tooles, Christmas Trees.

First use ________ Last use ________ Total times used ________

BUTYL NITRITE: Rush, Quick Silver, Thrust, White Out, Bolt, Bullet, Locker

Room, Climax, Doctor, Essence, Exotic.

First use ________ Last use ________ Total times used ________

CHLOROHYDROCARBONS: Aerosol Sprays, Cleaning fluids, Polish Remover,

Rubber Cement, Liquid Paper, Paint Thinner

First use ________ Last use ________ Total times used ________

HASHISH: Hash.

First use ________ Last use ________ Total times used ________

HASHISH OIL: Hash Oil.

First use ________ Last use ________ Total times used ________

FLOURINATED HYDROCARBONS: Hair Spray, Whipped Cream, Computer

Cleaner.

First use ________ Last use ________ Total times used ________

(continued...) Have you ever illegally used or experimented with any of the

following substances, drugs, or narcotics?

DRUG

*Please indicate the month and year for first and last use of the drug.

YES NO

MARIJUANA: Bud, Chronic, Primo, Skunk Weed, Gungi, Cess, Cheeba, Rope,

Blunt, Endo, Boom, Pot Reefer, Grass Weed, Dope, Ganja, Mary Jane, Acapulco,

Gold, Columbian gold, Joint, Roach, Tai Sticks, Doobie.

First use ________ Last use ________ Total times used ________

METHAMPHETAMINES: Crack, Crystal Meth., Speed, Glass, Peanut Butter, Natzi

Vitamins, Hydro, Ice, Co-pilot, Fire, chalk and Ice.

First use ________ Last use ________ Total times used ________

METHAQUALONE: Quaaludes, Ludes, Sopor, Black Beauties.

First use ________ Last use ________ Total times used ________

NITROUS OXIDE: Laughing Gas, Whip-Its, Nitro, Buzz Bomb, Shoot The Breeze,

Noss, N20.

First use ________ Last use ________ Total times used ________

STEROIDS: Anadrol, A-50, Anavar, D-Ball, Winstrol, Winstrol 5, Parabolin,

Premobolan, Proviron.

First use ________ Last use ________ Total times used ________

TETRAHYDROCANNABINOL: THC

First use ________ Last use ________ Total times used ________

COCAINE: Coke, Caine, Squirrel, Toot, Yeyo, Basuco, Bolo, Baby T, Beam Me Up

Scottie, Snow, Nose Candy, Flake, Blow, Big “C,” Lady, White, Snowbird.

First use ________ Last use ________ Total times used ________

CRACK COCAINE: Crack, Rock, Freebase, Boulders, Sheet Rock, Yahoo, Yeaho.

First use ________ Last use ________ Total times used ________

DESIGNER: Synthetic Heroin, China White, New Heroin, PCPY, PCE, PCP.

First use ________ Last use ________ Total times used ________

HEROIN: Chieva, China, Chinese Red, Mexican Brown, Poppy, Speedball, Trash,

Crap, Smack, Horse Mud, Brown Sugar, Junk, Black Tar, Big “H”, Pure Gram, Cap,

Bindle, Spoon, A Fix.

First use ________ Last use ________ Total times used ________

LYSERGIC ACID: LSD, Acid, Microdot, Paperboy, Bart Simpson, Big D,

Sunshine, “L”, Paper Acid, Purple Haze, White Lighting, Blue Heaven, Sugar Cubes,

Tabs.

First use ________ Last use ________ Total times used ________

MESCALINE: Mesc., Blue Caps, Buttons, Chief, Moon, San Pedro, Topi, Cactus

Head, Cactus Button.

First use ________ Last use ________ Total times used ________

(continued...) Have you ever illegally used or experimented with any of the

following substances, drugs, or narcotics?

DRUG

*Please indicate the month and year for first and last use of the drug.

YES NO

MORPHINE: Pectoral Syrup, Miss Emma, Blue Mister, Morf.

First use ________ Last use ________ Total times used ________

OPIUM: Joy Plant, Red Rock, Paregoric, Dover’s Powder, Parepectolin.

First use ________ Last use ________ Total times used ________

PEYOTE: Buttons, Cactus, Bad Seed, Cacti Joint, “P”, Mescy Nubs, Seni Tops,

Shaman.

First use ________ Last use ________ Total times used ________

PHENCYCLIDINE: PCP, Juice, Cadillac, Jet Fuel, Super Kools, Zombie Weed,

Animal Trang, Hog, Angel Dust, Love Boat, Lovely, Killer Weed, Whack, Dust,

Sherms.

First use ________ Last use ________ Total times used ________

PSILOCYBIN: Magic Mushrooms, Shrooms, Mexican Mushrooms, Pizza Toppers,

Caps.

First use ________ Last use ________ Total times used ________

GHB: Grievous Bodily Harm, “G”, Georgia Home Boy, Liquid Ecstasty, Liquid X,

Liquid E, Gamma-Oh, Goop, EZ Lay.

First use ________ Last use ________ Total times used ________

ROPHYNOL: Roofies, Ruffles, Rpohies, Forget Me Pill.

First use ________ Last use ________ Total times used ________

KETAMINE: Special K, Super K, “K” Vitamin K, Cat Valium.

First use ________ Last use ________ Total times used ________

FENTANYL: Tango and Cash, Apache, Murder8, Poison, King Ivory, White Jackpot.

First use ________ Last use ________ Total times used ________

DMT: Businessman’s high, Businessman’s LSD, Businessman’s special,

Businessman’s trip, Businessman’s high.

First use ________ Last use ________ Total times used ________

MDMA: Ecstasy, Vitamin E, Love Drug, Lucky Charmz, Mitisubishi, Clarity, Adam,

Lover’s Speed, Beans, Biscuits, Candy, Jellie Beans, Party Favors, Smurfs, Rolls,

“X”, “XTC”, Beavis and Butthead, Pikachu, Vitiamins.

First use ________ Last use ________ Total times used ________

OTHERS:

First use ________ Last use ________ Total times used ________

4. Have you used any illegal drugs in the last year? Yes _____ No _____

If “yes,” when?

Substance(s):

Number of times:

Last time (date):

5. Have you ever sold narcotics or drugs, including marijuana? Yes ____ No ___

If “yes,” total

profit:

Substance(s):

Number of times:

Last time (date):

6. Have you ever furnished, manufactured, cultivated, or possessed any drug, narcotic, or

other illegal substance? Yes _____ No _____

Substance:

Explain:

7. Have you committed any crimes not previously mentioned? Yes ____ No____

If “yes,” please

explain:

8. Have you ever been accused or been the victim of sexual harassment or discrimination

in the work place? Yes _____ No _____

Explain:

“ I am aware that any false statement or omission on this questionnaire will cause

my name to be removed from the eligibility list, or be cause for immediate

dismissal if any appointment was made.”

Do you understand this questionnaire? Yes _____ No _____

Do you have any questions about this questionnaire? Yes _____ No _____

X

Print Name

Social Security No.

Signature

Date

LOS ANGELES COUNTY SHERIFF’S DEPARTMENT

HEIGHT-WEIGHT RELATIONSHIP: Although there are no minimum or maximum height

requirements, the height-weight relationship of each applicant must either (1) fall within the ranges in

the following table, or (2) if the applicant’s height is not included on the table, found to be acceptable

after individual evaluation. Height measurements are made without shoes. Weight measurements are

made without shoes and coat. Applicants whose height. Individuals who do not meet the standard

shall have their body fat measured. Female candidates whose body fat is 33% or less may qualify.

Male candidates whose body fat is 22% or less may qualify.

MALE

HEIGHT WEIGHT HEIGHT WEIGHT 5 ft. 0 in. 110 lbs. To 143 lbs. 5 ft. 10 in. 144 lbs. To 185 lbs.

5 ft. 1 in. 112 lbs. To 146 lbs. 5 ft. 11 in. 148 lbs. To 191 lbs.

5 ft. 2 in. 115 lbs. To 149 lbs. 6 ft. 0 in. 152 lbs. To 197 lbs.

5 ft. 3 in. 118 lbs. To 152 lbs. 6 ft. 1 in. 156 lbs. To 203 lbs.

5 ft. 4 in. 121 lbs. To 155 lbs. 6 ft. 2 in. 160 lbs. To 209 lbs.

5 ft. 5 in. 124 lbs. To 158 lbs. 6 ft. 3 in. 164 lbs. To 215 lbs.

5 ft. 6 in. 128 lbs. To 163 lbs. 6 ft. 4 in. 168 lbs. To 221 lbs.

5 ft. 7 in. 132 lbs. To 168 lbs. 6 ft. 5 in. 172 lbs. To 227 lbs.

5 ft. 8 in. 136 lbs. To 173 lbs. 6 ft. 6 in. 176 lbs. To 233 lbs.

5 ft. 9 in. 140 lbs. To 179 lbs. 6 ft. 7 in. 180 lbs. To 239 lbs.

FEMALE

HEIGHT WEIGHT HEIGHT WEIGHT 5 ft. 0 in. 95 lbs. To 129 lbs. 5 ft. 10 in. 131 lbs. To 180 lbs.

5 ft. 1 in. 98 lbs. To 132 lbs. 5 ft. 11 in. 135 lbs. To 186 lbs.

5 ft. 2 in. 101 lbs. To 135 lbs. 6 ft. 0 in. 139 lbs. To 192 lbs.

5 ft. 3 in. 104 lbs. To 138 lbs. 6 ft. 1 in. 143 lbs. To 197 lbs.

5 ft. 4 in. 107 lbs. To 144 lbs. 6 ft. 2 in. 147 lbs. To 204 lbs.

5 ft. 5 in. 111 lbs. To 150 lbs. 6 ft. 3 in. 151 lbs. To 210 lbs.

5 ft. 6 in. 115 lbs. To 156 lbs. 6 ft. 4 in. 155 lbs. To 216 lbs.

5 ft. 7 in. 119 lbs. To 162 lbs. 6 ft. 5 in. 159 lbs. To 222 lbs.

5 ft. 8 in. 121 lbs. To 168 lbs. 6 ft. 6 in. 163 lbs. To 228 lbs.

5 ft. 9 in. 127 lbs. To 174 lbs. 6 ft. 7 in. 167 lbs. To 234 lbs.

I have read the Height/Weight requirements above and understand that I will not qualify for the

position, if I do not meet the standards as indicated.

PRINT NAME : _________________________________

SIGNATURE : _________________________________

DATE : _________________________________

S.T.A.R.S. Center – Quad Area, 11515 South Colima Road, Whittier, CA 90604